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Garlic-related dermatoses: Case report and review of the literature
Garlic-related Dermatoses: Case Report and Review of the Literature UtaJappe, BerndBonnekoh,Bjii,n M. Hausen,andHarald Gollnick Background: Garlic is widely appreciated as a spice and as a vegetable as well as an over-the-counter phytotherapeutic. From a dermato-allergological standpoint, several garlic-related adverse reactions have to be distinguished. Objective: The corresponding literature is reviewed briefly, with regard to our present observation of a cook, who contracted garlic-induced contact dermatitis being analyzed for its complex pathomechanism. Methods: The patient showed a positive type-IV patch test reaction for diallyl disulfide, a low molecular weight garlic ingredient; and strong, non-irritant reactions after 20 min and 24 hrs in the scratch chamber test with fresh total garlic. Resu/ts:Thus, in this case of an occupational dermatosis, protein contact dermatitis had to be considered, as well as allergic type-IV contact dermatitis as a co-existing pathomechanism. Conclusions: The spectrum of garlic-related adverse reactions comprises irritant contact dermatitis, with the rare variant of zosteriform dermatitis; induction of pemphigus, allergic asthma and rhinitis; contact urticaria; protein contact dermatitis; allergic contact dermatitis, including the hematogenic variant; as well as combinations thereof, as evidenced by our present case observation. Copyright 0 1999 by W.B. Saunders Company
ARLIC (Allium s&urn) belongs to the family Alliaceae. As a condiment, garlic is added to food to improve its flavor. Therapeutic uses have also been reported for some of garlic components that are allyls with disulfide and thiol groups. However, garlic is also considered to be both a type-1 and type-IV allergen. We present the case of a cook who developed garlic-induced allergic contact dermatitis as an occupational dermatosis, in whom a rare combination of immediate-, delayed-and late-type reactions to garlic are demonstrated.
G
Case Report A 24-year-old cook developed eczematous eruptions on the first, second, third, and fourth fingertips of the left hand. This condition started as redness, but progressed to include hyperkeratosis
From the Department ofDermatologp and Venezolo~, Otto-van-GuerickelJniversi& ofMagdeburg, Germay, and the Dermatolop Center, Buxtehude, GCWUZ?p Address covesjondence to Dr. Uta Jaibi)e, c/o Dr. XT Holland, Department ofMicrobiolo,, U&&y o&z& Leeds LS29JT, UK. Cqtyright 0 1999 by MUI. Saunders Company 1046.199x/99/1OOI-0008$~0,00/0 American
Journal
of Contact
Dermatitis,
and fissuring (Fig 1). He had worked as a cook for Greek and Italian restaurants for 5 years. Several patch tests were performed, including those directed at standard allergens, garlic extract in alcohol and in water, fresh garlic juice, and finely-ground garlic powder. Patch tests to the purified garlic allergens, diallyl disulfide and allitin, as well as the onion allergen, ally1 isothiocyanate, emulsified in petrolatum, were also performed. In addition, these substances were tested by prick, prick-to-prick, scratch, and scratch chamber tests (Table 1). The patch test was positive to diallyl disulfide, while scratch chamber test revealed strong immediate- and delayed-type reactions to raw garlic. As a control, the skin testing for garlic-induced, immediate-type reactions was performed under identical conditions in a total of 20 healthy persons and did not show any positive result, thereby excluding an irritant effect in our patient. Prick test with a commercial allergen solution of onion (1% in glycerol, ALK-Scherax, Hamburg, Germany) resulted in a positive reaction after 20 minutes. Using the Pharmacia CAP system FEIA (fluorescence enzyme immunoassay, Pharmacia AB, Uppsala, Sweden), specific IgE (immunoglobin E) antibodies to a wide spectrum of food l7ol
IO, No I (March),
1999:pj
37-39
37
38
Ja@pe et al
groups seem to represent the most critical garlic ingredients. Similar to drugs containing active sulfhydryl groups (eg penicillamine, captopril), they are known to have the potential to induce acantholysis in vitro and in viuo, leading to pemphigus vulgaris-like eruptions in genetically predisposed persons. Q Garlic may cau se an irritant contact dermatitis, which was illustrated by the cases of children who used a fresh garlic paste to treat minor bruises topically, and thereafter were affected by partly bullous burns in the treated skin areas.3M5A special variant of such a garlicinduced irritant dermatitis represents a zosteriform skin eruption, that developed under the occlusive application of garlic paste, performed in a segmentally localized manner because of onesided flank pains.6 Among the garlic-related, immunologic, immediate-type reactions, the induction of allergic bronchial asthma and rhinitis have been described.3 Cases of contact urticaria and protein contact dermatitis caused by garlic are well documented, especially in kitchen workers.7,8 Protein contact dermatitis is assumed to be triggered by as yet unidentified proteins, or protein complexes. As protein allergens of high molecular weight cannot penetrate the intact horny layer of the epidermis, a negative patch test, in conjunction with positive results for prick and scratch chamber testing, point to the diagnosis of protein contact dermatitis. Scratch chamber testing plays a pivotal role in the diagnosis of protein contact dermatitis, as it allows penetration of high molecular weight allergens through the scratch lines, and it may detect an urticarial immediate-type reaction after 20 minutes, and an eczematous delayed-type reaction, at an additional reading, after 24 hrs.7a8 In contrast, garlic ingredients of low molecular weight 1 u lfd1 e, allicin and ally1 propyldisul(ie diallyl d’s fide) have been identified as type-IV contact aller-
Figure 1. Unilateral garlic-induced eczema at the index fingertip of the left hand in a cook. As a right-handed person, the patient developed skin symptoms at the nondominant, left hand, used to grip the food when cutting by knife with the right hand.
allergens, including detected.
garlic and onion, were not
Discussion There is a relatively wide spectrum of garlicinduced non-allergic, and allergic, adverse reactions. In this regard, allyls with disulfide and thiol Table
1. Results
of Diagnostic
Allergy Rub Test
Allergen
Preparation
Garlic (slice) Diallyl disulfide 1% Allicin 1% Allylisothiocyanate O,l% CONTROLS Histamine Sodium chloride
20min
Testing Prick 20min
Scratch 20 min
Patch
20 min
24 hrs
Test
Scratch
48
72
96 hrs
negative negative negative negative
+ -
++ -
-
+++ +
+++ ++
+++ ++
+++ ++
-
-
-
-
negative ne.gative
+++ -
+++ -
n.d. -
-
-
-
20 min
Chamber
Test
24 hrs ++
-
+ n.d. n.d. n.d.
-
+-I-
-
Garlic-Related
gem. g~1o lMoreover, ingestion of raw garlic has been associated with hematogenic contact dermatitis,” with the sweat gland excretion probably playing an important role.‘* In our case of a cook, the occupational, garlicinduced hand eczema was a result of two coexisting allergic pathomechanisms. First, a latetype reaction (type-IV) towards the garlic ingredient diallyl disulfide was demonstrated, which did not cause any positive prick or scratch immediate-type reaction. Second, a concomitant protein contact dermatitis directed to another, as yet unidentified, ingredient of total fresh garlic had to be considered, because of positive nonirritant, immediate- and delayed-type reactions in the scratch chamber test. In addition, the patient showed an immediate type reaction to a total onion extract, without any coinciding delayed-type reaction. Ally1 isothiocyanate, an onion allergen, was also tested. It is generally known for its relatively low allergenic potential, and did not cause a positive test reaction in our patient. The existence of cross-reactivity between allergens from garlic and onion is a matter of controversial debate.13>14The fact that our patient tolerated garlic as a cooked or baked food, without any symptoms, may be explained by the heat instability of the allergenic constituents.15 Because of the present public tendency to favour nature remedies, a more widespread use of garlic, especially as a topical medicine, is to be expected. Consequently, an increased incidence of these discussed garlic-related adverse effects may have to be considered in the future.
Dematoses
39
References 1. Brenner S, Ruocco V, Wolf R, et al: Pemphigus factors. In vitro acantholysis by ally1 compounds allium. Dermatology 190: 197-202, 1995
and dietary of the genus
2. Ruocco V, Brenner S, Lombardi MLz A case of diet related pemphigus. Dermatology 192:373-374,1996 3. Canduela V, Mongil I, Carrascosa M, et al: Garlic: Always good for the health? BrJ Dermatol 132:161-162,1995 4. Garty BZ: Garlic burns. Pediatrics 91:658-659, 1993 5. Parish RA, McIntire S, Heimbach DM: Garlic burns: A naturopathic remedy gone awry. Pediatr Emerg Care 3:258259,1987 6. Farrel AM, Staughton RCD: Garlic dermatitis mimicking herpes zoster. Lancet 347: 1195, 1996 7. Hjorth N, Reed-Petersen J: Occupational protein contact dermatitis in food handlers. Contact Dermatitis 2:28-42, 1976 due to foods. 8. Fisher AA: Allergic protein contact dermatitis Current Contact News. Cutis 16:793-796, 1975 9. Papageorgiou C, CorbetJP, Menezes-Brandao F, et al: Allergic contact dermatitis to garlic. Identification of the allergens: The role of mono-, di- and trisulfides present in garlic. Arch Dermatol Res 275:229-234, 1983 10. Cronin E: Dermatitis of the hands in caterers. Contact Dermatitis 17:265-269, 1987 11. Burden AD, Wilkinson SM, Beck MI-I, Chalmers RJG: Garlicinduced systemic contact dermatitis. Contact Dermatitis 30: 299-3 15, 1994 12. Harris CM, Mitchell SC, Waring RH, et al: The case of the Black-speckled dolls: An occupational hazard of unusual sulphur metabolism. Lancet 3:492-493, 1986 13. Sinha SM, Pasricha JS, Sharma RC; et al: Vegetables responsible for contact dermatitis of the hands. Arch Dermatol 113:776-779, 1977 14. van-Ketel WG, De Haan I’: Occupational eczema from garlic and onion. Contact Dermatitis 453.54, 1978 15. Bleuminck E, Doeglas HMG, Klokke HA, et al: Allergic contact dermatitis to garlic. BrJ Dermatol87:6-8, 1972
ARLIC (Allium s&urn) belongs to the family Alliaceae. As a condiment, garlic is added to food to improve its flavor. Therapeutic uses have also been reported for some of garlic components that are allyls with disulfide and thiol groups. However, garlic is also considered to be both a type-1 and type-IV allergen. We present the case of a cook who developed garlic-induced allergic contact dermatitis as an occupational dermatosis, in whom a rare combination of immediate-, delayed-and late-type reactions to garlic are demonstrated.
G
Case Report A 24-year-old cook developed eczematous eruptions on the first, second, third, and fourth fingertips of the left hand. This condition started as redness, but progressed to include hyperkeratosis
From the Department ofDermatologp and Venezolo~, Otto-van-GuerickelJniversi& ofMagdeburg, Germay, and the Dermatolop Center, Buxtehude, GCWUZ?p Address covesjondence to Dr. Uta Jaibi)e, c/o Dr. XT Holland, Department ofMicrobiolo,, U&&y o&z& Leeds LS29JT, UK. Cqtyright 0 1999 by MUI. Saunders Company 1046.199x/99/1OOI-0008$~0,00/0 American
Journal
of Contact
Dermatitis,
and fissuring (Fig 1). He had worked as a cook for Greek and Italian restaurants for 5 years. Several patch tests were performed, including those directed at standard allergens, garlic extract in alcohol and in water, fresh garlic juice, and finely-ground garlic powder. Patch tests to the purified garlic allergens, diallyl disulfide and allitin, as well as the onion allergen, ally1 isothiocyanate, emulsified in petrolatum, were also performed. In addition, these substances were tested by prick, prick-to-prick, scratch, and scratch chamber tests (Table 1). The patch test was positive to diallyl disulfide, while scratch chamber test revealed strong immediate- and delayed-type reactions to raw garlic. As a control, the skin testing for garlic-induced, immediate-type reactions was performed under identical conditions in a total of 20 healthy persons and did not show any positive result, thereby excluding an irritant effect in our patient. Prick test with a commercial allergen solution of onion (1% in glycerol, ALK-Scherax, Hamburg, Germany) resulted in a positive reaction after 20 minutes. Using the Pharmacia CAP system FEIA (fluorescence enzyme immunoassay, Pharmacia AB, Uppsala, Sweden), specific IgE (immunoglobin E) antibodies to a wide spectrum of food l7ol
IO, No I (March),
1999:pj
37-39
37
38
Ja@pe et al
groups seem to represent the most critical garlic ingredients. Similar to drugs containing active sulfhydryl groups (eg penicillamine, captopril), they are known to have the potential to induce acantholysis in vitro and in viuo, leading to pemphigus vulgaris-like eruptions in genetically predisposed persons. Q Garlic may cau se an irritant contact dermatitis, which was illustrated by the cases of children who used a fresh garlic paste to treat minor bruises topically, and thereafter were affected by partly bullous burns in the treated skin areas.3M5A special variant of such a garlicinduced irritant dermatitis represents a zosteriform skin eruption, that developed under the occlusive application of garlic paste, performed in a segmentally localized manner because of onesided flank pains.6 Among the garlic-related, immunologic, immediate-type reactions, the induction of allergic bronchial asthma and rhinitis have been described.3 Cases of contact urticaria and protein contact dermatitis caused by garlic are well documented, especially in kitchen workers.7,8 Protein contact dermatitis is assumed to be triggered by as yet unidentified proteins, or protein complexes. As protein allergens of high molecular weight cannot penetrate the intact horny layer of the epidermis, a negative patch test, in conjunction with positive results for prick and scratch chamber testing, point to the diagnosis of protein contact dermatitis. Scratch chamber testing plays a pivotal role in the diagnosis of protein contact dermatitis, as it allows penetration of high molecular weight allergens through the scratch lines, and it may detect an urticarial immediate-type reaction after 20 minutes, and an eczematous delayed-type reaction, at an additional reading, after 24 hrs.7a8 In contrast, garlic ingredients of low molecular weight 1 u lfd1 e, allicin and ally1 propyldisul(ie diallyl d’s fide) have been identified as type-IV contact aller-
Figure 1. Unilateral garlic-induced eczema at the index fingertip of the left hand in a cook. As a right-handed person, the patient developed skin symptoms at the nondominant, left hand, used to grip the food when cutting by knife with the right hand.
allergens, including detected.
garlic and onion, were not
Discussion There is a relatively wide spectrum of garlicinduced non-allergic, and allergic, adverse reactions. In this regard, allyls with disulfide and thiol Table
1. Results
of Diagnostic
Allergy Rub Test
Allergen
Preparation
Garlic (slice) Diallyl disulfide 1% Allicin 1% Allylisothiocyanate O,l% CONTROLS Histamine Sodium chloride
20min
Testing Prick 20min
Scratch 20 min
Patch
20 min
24 hrs
Test
Scratch
48
72
96 hrs
negative negative negative negative
+ -
++ -
-
+++ +
+++ ++
+++ ++
+++ ++
-
-
-
-
negative ne.gative
+++ -
+++ -
n.d. -
-
-
-
20 min
Chamber
Test
24 hrs ++
-
+ n.d. n.d. n.d.
-
+-I-
-
Garlic-Related
gem. g~1o lMoreover, ingestion of raw garlic has been associated with hematogenic contact dermatitis,” with the sweat gland excretion probably playing an important role.‘* In our case of a cook, the occupational, garlicinduced hand eczema was a result of two coexisting allergic pathomechanisms. First, a latetype reaction (type-IV) towards the garlic ingredient diallyl disulfide was demonstrated, which did not cause any positive prick or scratch immediate-type reaction. Second, a concomitant protein contact dermatitis directed to another, as yet unidentified, ingredient of total fresh garlic had to be considered, because of positive nonirritant, immediate- and delayed-type reactions in the scratch chamber test. In addition, the patient showed an immediate type reaction to a total onion extract, without any coinciding delayed-type reaction. Ally1 isothiocyanate, an onion allergen, was also tested. It is generally known for its relatively low allergenic potential, and did not cause a positive test reaction in our patient. The existence of cross-reactivity between allergens from garlic and onion is a matter of controversial debate.13>14The fact that our patient tolerated garlic as a cooked or baked food, without any symptoms, may be explained by the heat instability of the allergenic constituents.15 Because of the present public tendency to favour nature remedies, a more widespread use of garlic, especially as a topical medicine, is to be expected. Consequently, an increased incidence of these discussed garlic-related adverse effects may have to be considered in the future.
Dematoses
39
References 1. Brenner S, Ruocco V, Wolf R, et al: Pemphigus factors. In vitro acantholysis by ally1 compounds allium. Dermatology 190: 197-202, 1995
and dietary of the genus
2. Ruocco V, Brenner S, Lombardi MLz A case of diet related pemphigus. Dermatology 192:373-374,1996 3. Canduela V, Mongil I, Carrascosa M, et al: Garlic: Always good for the health? BrJ Dermatol 132:161-162,1995 4. Garty BZ: Garlic burns. Pediatrics 91:658-659, 1993 5. Parish RA, McIntire S, Heimbach DM: Garlic burns: A naturopathic remedy gone awry. Pediatr Emerg Care 3:258259,1987 6. Farrel AM, Staughton RCD: Garlic dermatitis mimicking herpes zoster. Lancet 347: 1195, 1996 7. Hjorth N, Reed-Petersen J: Occupational protein contact dermatitis in food handlers. Contact Dermatitis 2:28-42, 1976 due to foods. 8. Fisher AA: Allergic protein contact dermatitis Current Contact News. Cutis 16:793-796, 1975 9. Papageorgiou C, CorbetJP, Menezes-Brandao F, et al: Allergic contact dermatitis to garlic. Identification of the allergens: The role of mono-, di- and trisulfides present in garlic. Arch Dermatol Res 275:229-234, 1983 10. Cronin E: Dermatitis of the hands in caterers. Contact Dermatitis 17:265-269, 1987 11. Burden AD, Wilkinson SM, Beck MI-I, Chalmers RJG: Garlicinduced systemic contact dermatitis. Contact Dermatitis 30: 299-3 15, 1994 12. Harris CM, Mitchell SC, Waring RH, et al: The case of the Black-speckled dolls: An occupational hazard of unusual sulphur metabolism. Lancet 3:492-493, 1986 13. Sinha SM, Pasricha JS, Sharma RC; et al: Vegetables responsible for contact dermatitis of the hands. Arch Dermatol 113:776-779, 1977 14. van-Ketel WG, De Haan I’: Occupational eczema from garlic and onion. Contact Dermatitis 453.54, 1978 15. Bleuminck E, Doeglas HMG, Klokke HA, et al: Allergic contact dermatitis to garlic. BrJ Dermatol87:6-8, 1972